L12 Swallowing Flashcards
five phases of swallowing
- Anticipatory
- Oral preparatory
- Oral Phase
- Pharyngeal Phase
- Oesophageal Phase
What does MBSImp stand for
Modified Barium Swallow Impairment Profile
what is MBSimp
- a standardized approach to the instruction, assessment, and reporting of physiologic swallowing impairment
- 17 components of the adult swallowing mechanism
- includes a scoring metric
MBSImp Components
- Lip closure
- Tongue control during bolus hold
- Bolus preparation/mastication
- Bolus transportation/lingual motion
- Oral residue
- Initiation of pharyngeal swallow
- Soft palate elevation
- Laryngeal elevation
- Anterior hyoid excursion
- Epiglottic movement
- Laryngeal vestibular closure
- Pharyngeal stripping wave
- Pharyngeal contraction
- Pharyngoesophageal segment opening
- Tongue base retraction
- Pharyngeal residue
- Esophageal clearance upright position
what occurs during the oral and oral prepatory phases of swallowing
the sealing of the oral cavity, mastication of the bolus and transfer of bolus to the oropharynx
difficulty sicking or with bolus formation and propulsion
increased tone in lips/cheeks
sign of dysphagia
anterior spillage of food, drinks and saliva
reduced lip seal
sign of dysphagia
build up of material in lateral sulci
reduced buccal tone
sign of dysphagia
biting of tongue/cheeks and impaired bolus formation
reduced oral sensation
sign of dysphagia
difficulty with bolus formation and propulsion
reduced tongue movement
sign of dysphagia
difficulty with mastication
reduced jaw movement
sign of dysphagia
loss of bolus from oral cavity
tongue protrusion
sign of dysphagia
- difficulty placing spoon/teat
- food/liquid pushed out of mouth
tongue thrust
sign of dysphagia
difficulty propelling bolus posteriorly
disorganised anterior or posterior tongue movement
sign of dysphagia
difficulty breaking down bolus during mastication and manipulating bolus
dry oral mucosa
sign of dysphagia
involuntary lip and tongue movements
tardive dyskinesia
sign of dysphagia
reduced recognition of bolus or inability to initiate swallow
swallow agnosia/apraxia
sign of dysphagia
what occurs during the pharyngeal phase of swallowing
- Reflexive initiation of the swallow.
- The velum raises and seals the nasal cavity to prevent nasal regurgitation
- the vocal folds close
- the epiglottis closes over the trachea.
- The pharynx contracts and pushes bolus down.
- The upper oesophageal sphincter opens to let the bolus pass through and closes afterwards to prevent retrograde movement
breakdowns which occur in the pharyngeal phase of the swallow
- Delay initiating the pharyngeal swallow
- Weak tongue base retraction
- Nasal regurgitation
- Reduced pharyngeal contraction
- Poor airway protection
- Reduced hyolaryngeal excursion
- Impaired UOS opening
- Reduced laryngeal sensation
- Weak reflexive cough
aspiration
entry of material below the level of the true vocal cords
Aspiration : Penetration Aspiration Scale (Rosenbek et al. 1996)
- Material does not enter the airway
- Material enters airway, remains above the vocal folds, and is ejected from the airway.
- Material enters the airway, remains above the vocal folds, and is not ejected from the airway.
- Material enters the airway, contacts the vocal folds, and is ejected from the airway.
- Material enters the airway, contacts the vocal folds, and is not ejected from the airway.
- Material enters the airway, passes below the vocal folds and is ejected into the larynx or out of the airway.
- Material enters the airway, passes below the vocal folds and is not ejected from the trachea despite effort.
- Material enters the airway, passes below the vocal folds, and no effort is made to eject
what occurs during the oesophogeal phase
- The bolus is transported through the oesophagus by peristalsis into the stomach.
- The lower oesophageal sphincter opens to allow the bolus into the stomach and then closes to prevent reflux/regurgitation.
breakdowns occuring in the oesophageal phase
- Food impaction
- Impaired oesophageal clearance
- Reflux
- Regurgitation
- Laryngopharyngeal reflux
- Oesophageal web
- Diverticulum
- Schatzkis ring
- Fistula
- GORD
- Achalasia
- Oesophageal cancer
- Oesinophilic oesophagitis
Causes of Dysphagia
stroke
- Cortical
- Subcortical
- Brainstem
what is iatrogenic dysphagia
dysphagia caused by medical treatment
1. Medication
2. Chemo/Radiation
3. Surgery
4. Intubation
5. Tracheostomy
Causes of dysphagia
cancer
- Head and neck
- Lung
- Brain tumour
- Chemoradiation
Causes of dysphagia
Neurological
- Muliple sclerosis
- Motor neuron disease
- Guillain Barre syndrome
- Parkinson’s disease
- Huntington’s disease
- Myasthenia gravis
- Head injury/trauma
- Dementia
causes of dysphagia
gastroenterological
- Oesophageal cancer
- Achalasia
- GORD
- Diverticulum/web
- Oesinophilic oesophagitis
- Bariatric surgery
causes of dysphagia
respiratory
- COPD
- Obstructive sleep apnea
- Tracheostomy
- Intubation
- COVID-19
causes of dysphagia
paeds
- Pre-term babies
- Cardiac/pulmonary diseases
- Congenital syndromes
- Cerebral palsy
- Structural
- Acquired (tumour, trauma)
- Behavioural (food refusal)
causes of dysphagia
other
- Cervical spine surgery
- Thermal/caustic burns
- Infectious diseases (HIV, polio)
- Psychiatric
- Functional
complications of dysphagia
- Aspiration (/aspiration pneumonia)
- Risk of choking episodes
- Weight loss
- Dehydration
- Malnutrition
- Feeding tube dependency
- Antibioic cover
- Increased or prolonged hospital admissions
- Impaired quality of life
immediate signs of aspiration
- Wet vocal quality
- Multiple swallows
- Coughing when drinking or during meals
- Respiratory wheeze (ins/exp)
- ? Drop in oxygen levels
delayed signs of aspiration
- Spiking temperature
- Weight loss
- Repeated chest infections
- Malnutrition
- Dehydration
- Pneumonia right lobe > left
important factors to consider in aspiration
- Patient’s response to aspiration (effective/ineffective cough, silent aspiration)
- Amount of aspiration
- Frequency of aspiration
- Type of aspirate:
- oropharyngeal secretions
- liquid
- food
- reflux (pH value - acidic)
predictors of aspiration pneumonia
Langmore et al, 1999
- Smoking
- Dependency for feeding
- Tube feeding
- Polypharmacy
- Multiple medical diagnoses
- Number of decayed teeth
- Dependent for oral care
groups most affected by dysphagia
- Pre-term babies
- Children with congenital syndromes
- Cerebral palsy
- Stroke
- Nursing home residents
- People with cognitive impairment and dementia,
- People who are hospitalised,
- Head and neck oncology patients
- Critical care/intensive care
- Patients with progressive neurological conditions
